Profile of participants
Most of the participants were health care providers (14 gynecologists/physicians, 13 staff nurses, and 1 health assistant) and the remaining were administrators (6) and a counselor (1). Participants’ professional experience varied widely (9
months to 37
years) and they had different responsibilities in abortion service provision such as counselling, treatment and record keeping. Of the 35 participants, 26 were female and 9 were male. Most participants provided clinical services, including abortions and treatment of abortion-related complications, and also kept and prepared reports on hospital statistics. Participants worked in the hospitals’ abortion clinics, post-abortion care units, emergency rooms, gynaecological wards, and administrative units. Data were analysed by type of participant to assess whether there were different views or opinions on the major themes, and no major differences were observed.
The key themes emerging from the data analysis were: perceived benefits of abortion legalization, health worker views on abortion patients, concerns about low contraceptive use and repeat abortion after legalization, and abortion disclosure in clinical care before and after legalization. Sex-selective abortion also emerged as a theme during the analysis, and these findings have been published elsewhere [21
]. Across these themes, the stigma of abortion was found to intersect with and arise from socio-cultural norms about pre-marital sex, the role of husbands, and gender roles. We therefore discuss these issues where they pertain in the discussion of results.
Perceived benefits of abortion legalization
Many providers interviewed (23 out of 35) thought legalization improved maternal health and was responsible for a reduction in maternal mortality and morbidity. Participants stated that currently there were fewer post abortion complications compared to the pre-legalization period. Overall the providers expressed positive views of abortion legalization. However, three participants indicated that the abortion complications from rural areas have not declined as in urban areas, believing improvements in access to safe abortion are concentrated in the more populated urban areas.
"Inside the valley [capital city],] it [complications from abortion] has reduced, but from outside, it’s still the same…because there are more [abortion] centers in the valley, not only the CAC centers, but there are other private centers…Also they are more accessible."
"Earlier in our hospital some women used to come with severe complications after having an abortion in illegal and unsafe places and from unskilled providers. They used to come with severe complications. Such cases have declined and now we don’t have to deal with them. Women used to come with uterine perforations and at the last stage [close to death], which has declined now."
Participants believed that the types and severity of complications with which patients present at the hospitals had changed. Declines in the number of women presenting with septicaemia, infection, uterine perforation and rupture, septic shock and severe bleeding in the post legalization period were noted by the health care workers. This perception could reflect optimism about the benefits of legalization, and an observable effect of the shift in the safety of abortion.
Participants (14 out of 35) reported that prior to legalization women were more likely to obtain abortions from untrained abortion providers that included auxiliary health workers, traditional birth attendants, and Ayurvedic doctors. Consequently, women were more likely to present with complications from the insertion of sticks, sharp objects, catheters, and wooden pieces and the use of unsafe medicines, herbs, honey, cow dung, tree bark, and antiseptics, like Betadine and Dettol. As a result, severe complications such as septicaemia, uterine perforation, septic shock and severe bleeding were common.
"People who had visited midwives, traditional birth attendants, Vaidyas [Ayurvedic doctors], those who had taken honeyaand such other medicines used to come."
"I have seen women coming with sticks being inserted and they have some kind of a paste, they call “pitix”. I don’t know what it contains but it’s like Fevicol [sticky adhesive used for bonding materials] and they get it from India…..And then there are some herbs.....mostly herbs and sticks and pastes."
Participants suggested that an increasing proportion of women are obtaining safe abortion services from hospitals and certified facilities for abortion care. This rise was attributed by some to women’s greater awareness of and faith in abortion services. Furthermore, they stated that women were seeking treatment at the hospital for abortion-related complications more quickly, rather than waiting until symptoms worsened.
"It is cheaper here and [women] think that it is safer here … They say that when anything happens you manage, so we come here…They think it’s safe."
"I think there has been an increase in the awareness level among women and people. So, they immediately come for abortion services [to treat complications]. Maybe for that reason we have not seen many severe cases. When they have bleeding, they come to us."
Nevertheless, a few providers pointed to the need to improve women’s knowledge of the abortion law. In particular, they noted the ongoing issue of women visiting the facilities after they had passed the gestational age limit and, thus, not being able to receive services. They reported that uneducated or poor women who have less information and knowledge about safe services were more likely to present at later dates.
"[Rich people] know that now there is legal abortion and they ask for the abortion directly— they ask for a doctor. I don’t want this baby, I want an abortion…But poor people do not know [up until] how many weeks they can do the abortion. They come—sometimes they come after 15weeks, 20weeks.
A few participants (5 out of 35) were concerned that the number of medical abortion related complications was increasing due to the use of ineffective and unregistered medical abortion pills obtained mainly from private pharmacists and chemists and other uncertified health personnel.
"Now, medical abortion drugs are known to all pharmacists and medical shop keepers. They give drugs to the clients without any assessment. Nowadays, whenever we take the history [of a woman presenting with complications]… everyone will say “after taking the medicine” and when we ask where did you take it, they say from the medical store."
On the other hand one participant stated the need for medical abortion service expansion in the country.
"Medical abortion service is being piloted in the country…I think it should be promoted to the grass-root levels."
Views on abortion patients
Participants offered many reasons that women sought abortion: being unmarried, pregnancy as a result of an extramarital relationship, unwanted pregnancy, maternal health problems, sex-selection, contraceptive failure, ashamed to use contraceptives, birth spacing, and for limiting family size. Some participants stated that the reasons women sought abortion were similar both before and after legalization. However, a few health care workers noted a shift in the abortion seeking behaviour of some women and in the composition of patients. They noted that more educated people, those with higher socio-economic status, and unmarried girls used to visit private hospitals or go to India prior to legalization, however, now they are accessing services from government health facilities.
"The reason for abortion before and now is the same because before legalization some used to have an abortion because of having many children, some because they were unmarried…Though they know about [family planning], many come saying that [the pregnancy] has happened by chance. Some are ignorant about [family planning], some come because their husbands don’t want it, and some feel ashamed to do family planning."
"Now, rich people also come there. They know that now there is legal abortion and they ask for the abortion directly."
Some participants held negative judgments of women’s reason for abortion, suggesting that women seeking abortion held careless attitudes towards ending pregnancy. There was concern among a few (9 out of 35) that society had become more open about sexual relationships and, ‘even the unmarried ones’ were openly coming for abortion service. Negative judgments held by society and themselves toward unmarried women seeking abortion care were also expressed.
"[Women] are more careless; as they know we have abortion services…They come for an abortion without having a justifiable indication. [They come] even for small indications. People have taken abortion services for granted."
"The facilities of abortion are being misused…Unmarried women are having abortions frequently as well. I have heard that unmarried women visit the private clinics often."
Abortion among unmarried women had particularly negative connotations, as premarital sex is strongly condemned in Nepalese society. Although socio-cultural values are changing, marriage is predominantly arranged, and the reproductive and marriageable status of young women has social and financial implications to the family. There was concern among some (12 out of 35) health care workers that in the post-legalization period more unmarried and teenaged girls were receiving abortion services. Although legally acceptable, moral and social concerns were raised by the providers on abortion sought by unmarried women. One participant attributed the growing number of abortions among unmarried young women to working in massage parlours and dance restaurants.
"Many teenagers these days have sexual relationships and they come here and [have an abortion] themselves and do not inform their family, which is a bad thing."
"There are so many young people, so many dance restaurants, massage parlours. All these things have opened up, you know…So, a kind of prostitution and young people seeking jobs…And then, you know, the incidence of unmarried mothers is on the rise and since abortion is legal now they come."
A few (6 out of 35) participants were unaware of specific provisions of the abortion law that ban sex-selective abortion; allow abortion without husband’s consent, and the legality of abortion regardless of marital status. Misperceptions of the abortion law were, notably, not present among the physicians providing abortion care - two health administrators, one health assistant and three nurses had inaccurate knowledge.
"They have to come within 12weeks…and they should be married…and the husband should give the permission.
"- Health Assistant"
"It’s illegal for unmarried women to my knowledge…because, you know; the culture does not allow it."
"- Physician (Health Care Administrator)"
The discontinuity between Nepali culture and the provision of the law permitting women to obtain abortion without a husband’s consent, may pose a barrier to comprehension of the law, even among health-care workers involved in abortion and post-abortion care. Efforts to raise awareness and understanding among health care workers involved in abortion care on the legal provisions could help to correct misunderstandings, but this would not necessarily address their cultural and moral concerns.
Concerns about contraceptive use and repeat abortion
Several different views were aired by the participants regarding contraceptive use in the legal abortion context. Some participants (10 out of 35) were concerned that less attention was being given to the provision and use of family planning. Two perceived contraceptive use to have declined; while two felt that post-abortion contraceptive use had increased. Overall, participants stressed the need to deliver the message that abortion is not a substitute for family planning, and articulated concerns about contraceptive continuation following abortion.
"When [women] come here for CAC [abortion] we provide them family planning methods for once [for example] she might take pills for a month but we don’t know if she takes the pills regularly"
A few participants (6 out of 35) were concerned about repeat abortion, believing that abortion was taken more lightly in the post legalization period and fearing that it could lead to infertility, pelvic inflammatory disease, and perforation. They described repeat abortions as a negative impact of abortion legalization. However, empathy towards women having multiple abortions was also articulated, as well as the need for efforts to discourage repeat abortion by promoting counselling and family planning.
"If they do it once or twice, it is fine, but if you go and stay there [at the hospital] you can see the same women coming to have an abortion 4–5 times. However, our objective is not to have her repeat abortion. It also means that she has not received counselling services and she has not been motivated to use family planning or contraception."
Disclosure of abortion history before and after legalization
Participants indicated that women’s willingness to disclose abortion history was affected by the social context of abortion. Providers found that women were more open in sharing their abortion history post-legalization. This had consequences for documentation practices; a few participants (7 out of 35) mentioned that in the post-legalization period more details were being recorded on induced abortion history including place, person, method and time when the abortion was performed and gestational size at the time of abortion. This practice represents a change from the pre-legalization period where confidential terms were used to denote induced abortion. This change can have important implications for clinical care, as providers reported that women continue to present for complications from unsafe abortions.
"Now it is easier for us to take their detailed history. [Women] do not fear disclosure or a loss of confidentially. Therefore, it has been easier for us to treat women…They frankly say that they did this and so they came for an examination and treatment. Whereas earlier sometimes we had to take them in a separate room, sometimes they used to whisper in our ears."
Conversely, participants (12 out of 35) spoke of the stigma and need for secrecy that remains in the post-legalization period. Many noted that probing and counselling were still required to take a detailed history on induced abortion in post-abortion care clinics. Furthermore, counselling skills and the provider’s ability to take women into confidence determined the disclosure of abortion history; providers explained to women that an accurate medical history is best for high quality and appropriate care.
"Even after legalization people do not give their actual history of abortion. After talking for 15–20 minutes they come out with their real history. Most patients do not tell us that."
"That also depends on how much you counsel [women] because we usually tend to take them into confidence and tell them if you don’t give a correct history you won’t get proper treatment…so usually it is also the skill of the provider on how to get medical history from the patient."
The health workers noted that women’s fear of being scolded by providers for going to the wrong place (non-certified or illegal) was one of the reasons for their hesitation to disclose abortion history after legalization. Furthermore, women attempt to conceal the history of abortions performed beyond the gestational limits allowed for legal abortion. In addition, providers reported that unmarried women tend to conceal their history because they are fearful mistreatment from providers.
"Unmarried also do it [abortion] and they don’t want to tell about it openly so I think they hide it. The other reason is that they are fearful of being scolded or they are afraid that if they tell that [abortion] then they will not be treated well."